Lesson V - ECG Rhythm Abnormalities

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Regular atrial activity with a "clean" saw-toothappearance in leads II, III, aVF, and usually
discrete 'P' waves in lead V1. The atrial rate is usually about 300/min, but may be as slow as
150-200/min or as fast as 400-450/min.

Untreated A-flutter often presents with a 2:1 A-V conduction ratio. This is the most
commonly missed supraventricular tachycardia because the flutter waves are often difficult to
find when there is 2:1 ratio. Therefore, always think "atrial flutter with 2:1 block" whenever
there is a regular supraventricular tachycardia @ ~150 bpm! (You won't miss it if you look
for it in a 12-lead ECG)

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In this ECG rhythm strip, arrows point to atrial flutter waves @

280bpm with ventricular rate @ 140bpm (atrial flutter with 2:1
block)

The ventricular response may be 2:1, 3:1 (rare), 4:1, or irregular depending upon the AV
conduction properties and AV node slowing drugs on board (e.g., digoxin, beta blockers).

5. Ectopic Atrial Tachycardia and Rhythm

Ectopic, discrete looking, unifocal P' waves with atrial rate <250/min (not to be confused
with slow atrial flutter)

Ectopic P' waves usually precede QRS complexes with P'R interval < RP' interval (i.e., not
to be confused with paroxysmal supraventricular tachycardia with retrograde P waves
appearing shortly after the QRS complexes).

Ventricular response may be 1:1 or with varying degrees of AV block (especially in digitalis
toxicity, as shown in this 3-lead ECG with 2:1 block).

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